1. Crew Resource Management & The Command Officer
Proven Tool for a Safer Scene Control
Crew Resource Management & The Command Officer
Bob Bartosz Photo
Partnering for Safe Leadership
Ruidoso, NM
May 7, 2008
Battalion Chief John Tippett
Montgomery County Fire & Rescue Service (MD)

2. What do we hope to accomplish today?
Interactive discussion.
Preserve “good” traditions.
Acquaint you with “new”
approach to command &
control.
Provide tool you can
use beginning today.
Safety Based Culture
Non-Punitive Approach to Error

3. Is there a problem with the way we do business?

4. Acceptable Losses? 105 fatalities to date* 2006 Statistics
106 firefighters died while on duty in volunteer, 29 career.
6 multiple fatality incidents, 17 killed.
22 killed during brush, grass, or wildland firefighting.
36 died at the scene of a fire.
15 died responding to or returning from emergency incidents.
9 died engaged in training activities.
20 died after the conclusion of their on-duty activity.
50 died from heart attacks.
19 killed as a result of vehicle crashes.

5. Reasons & Costs
Better protection, aggressive tactics, lighter weight construction and improved handling capabilities of heavy apparatus are putting firefighters at greater risk.
Non-fatal firefighter injuries and prevention efforts cost anywhere from $2.8 billion to $7.8 billion per year. (NIST Report on Consequences of Fire Fighter Injuries )

6. Why isn’t technology enough?

7. “Normalization of Deviance”…

8. …becomes our nemesis

9. …To err is human… Error Management Marcus Tullius Cicero 106-43 B.C.
1 Fatality 10
Lost Time Injuries
100
Minor Injuries
1000 No Loss Accidents
10,000 UNSAFE ACTS!

10. Human Factor Error Causes Gordon Dupont’s “Dirty Dozen”
Lack of Communication
Complacency
Lack of Knowledge
Distraction
Lack of Teamwork
Fatigue
Lack of Resources
Pressure
Lack of Assertiveness
Stress
Lack of Awareness
Norms

11. Who Carries the Load?

12. When Things Go Wrong . . . How It Is Now . . . How It Should Be . . .
You are highly trained
You are human
and
and
Humans make mistakes
If you did as trained, you would not make mistakes so so
Let’s also explore why the system allowed, or failed to accommodate your mistake
You weren’t careful enough so
and
You should be PUNISHED!
Let’s IMPROVE THE SYSTEM!

13. Layers of Defense Trap Crew Errors
Use All Resources
Maintain Situational Awareness
Follow SOPs
High Level of Proficiency

14. You may not know where the holes are
Use All Resources
Follow SOP’s
Maintain Situational
Awareness
High Level of Proficiency
James Reason’s “Swiss Cheese”

15. When the holes line up… DISASTER! Use All Resources Follow SOP’s
Maintain Situational
Awareness
DISASTER!
High Level of Proficiency
James Reason’s “Swiss Cheese”

16. Crew Resource Management
What it is
Where it came from
How it works
Why we should use it
How we know it works

17. What Is Crew Resource Management?
Force multiplier
Uses all resources
Enhances supervision
Improves safety
Raises level of
awareness for
those engaged

18. Crew Resource Management (CRM) is a tool created to optimize human performance by reducing the effect of human error through the use of all resources.

19. Where Did It Come From? Aviation Community
Air Crashes Dominated Industry Attention
Technology Only Went So Far
1970’s –Dr. Robert Helmreich and CVRs

20. Helmreich’s Error Management Model
AVOID
TRAP
MITIGATE

21. How Does It Work? Six Principles Communication Decision-Making
Task Allocation
Teamwork
Situational
Awareness
Debrief*

23. Communication Barriers and bias block effective communication
Standard language benefits all
Practice “active” listening
Divide duties to prevent overload
Minimize distractions
Establish Inquiry/Advocacy patterns
Clear, Concise, Complete
Respectful
Bishop’s Assertive Statement

24. Communication Active Listening Face individual(s) Maintain eye contact
Only one person speaks at a time
Formulate reply after other person speaking finishes talking
Distractions
Turn down radio(s)
Phones on vibrate
No multi-tasking during periods of high stress
Ambient noise
Adjourn to quiet location

25. “Sterile” Command Post
Everyone needs to be “all business” when it’s time for business.
IC sets the tone for the CP.
Photo by Carlos Alfaro

26. Todd Bishop’s Assertive Statement
How to talk “up”
the chain of command
If you are a subordinate:
– use the technique
If you are a supervisor:
– LISTEN FOR THE PROCESS!

27. 5 Easy Steps Opening/attention (Call the supervisor by name or rank)
State concern/owned emotion (I’m concerned about…)
State the problem as you see it (Someone is going to get hurt if we…)
State a solution (I think we can do it another way…)
Obtain agreement (aka buy-in) (Does this make sense to you?)

28. Critical Decision Making
Recognize problems
Continue to “fight the fire”
Maintain SA
Assess hazards
Assess resources
Solicit solutions
Make a decision!

29. Klein
Method
Recognition Primed
Naturalistic
Cue Based

30. Decision Making Cue Based
Compare existing knowledge base against situation
Improve base through
Training
Experience
Knowledge
Case studies

31. “blink” Rapid Cognition Thin-slicing
Ability of the unconscious to find patterns in situations and behaviors based on very narrow slices of experience.
Automated, accelerated recognition of identifiable patterns.
“Coup d’oeil” - the power of the glance
- Malcolm Gladwell

32. Klein, Gladwell & Today’s Fire Officer

33. Task Allocation Know your limits Know your crew’s limits
Capitalize on strengths
Seek out “experts”
“Eat the elephant one bite at a time”

34. Task Allocation Exercise
What You Have
3 Story MFD
Fire on 2 floors and through roof
Type V Construction
Wood Truss Roof

35. Who’s On the Way… BC1 28 years, 6 as Ops BC 14 years in busiest areas
EFO Grad
Bachelor’s in Fire Protection
EMS BC
16 years, 2 as EMS BC
12 years in Suppression ranks
2 years as Training Captain
Associates’ Degree, EMS
Fire Prevention AC
20 years
6 in Ops as FF, Remainder of time in Fire Prevention
EFO Grad
Bachelor’s in Fire Protection
NIMS Instructor
Operations AC
34 years, 2 as Ops Chief
12 as Training DC
4 as Arson BC
8 as Safety Captain
Bachelor’s in Fire Service Management

36. Who Gets the Job? Fire Attack Safety Officer Senior Advisor
Roof Sector

37. Teamwork Leadership Followership
Photo by Bob Bartosz, Camden Fire Department

38. Teamwork Leadership Authority Mentoring Mandated by rank
Derived through respect
Mentoring
Lead by example
Admit mistakes
Be technically competent
Share knowledge

39. Teamwork #1 Priority: Continuous Risk vs Reward Evaluation
Conflict Resolution
Focus on issue
Keep ego in check
Listen
Mission Analysis
#1 Priority:
Continuous
Risk vs Reward
Evaluation

40. Understands human behaviors
Teamwork
FOLLOWERSHIP
Self Assessment
Physical Condition
Mental Condition
Attitude
Understands human behaviors

41. Teamwork Followership Respect authority Personal Safety Crew Safety
Accepts authority
Knows authority limits
Leader success
Good communication skills
Learning attitude
Ego in check
Balance assertiveness/authority
Accept orders
Demand clear tasks
Admit errors
Provide feedback
Adapt

42. How Well Do You Team?

43. Situational Awareness
Point where perception and reality collide
Reality always wins
Beware of loss factors
Ambiguity
Distraction
Fixation
Overload
Complacency
Unresolved discrepancy

44. Hazardous Attitudes Invulnerability Anti-authority Impulsivity Macho
Resignation
“Air Show Syndrome”
“Pressing”
Refers to an individual’s frame of mind. First 5 are FAA.

45. Good Situational Awareness
Good crew coordination
Proper task completion
Understanding
Smooth ride
Crisp and appropriate radio calls
Use of checklists

46. Preventing Loss of Situational Awareness
Crew mental joggers
“What do we have here?”
“What’s going on here?”
“How are we doing?”
“Does this look right?”

47. Preventing loss of Situational Awareness
Personal mental joggers
“What do I know that they need to know?”
“What do they know that I need to know?”
“What do we all need to know?”

48. Debrief Pre-Brief Facilitate Analyze Topic Decorum Operations
Human Behaviors

49. Why Should We Use CRM? Error is a fact of all performance
Command becoming more complicated
Command successes are a function of teamwork
Proven success in multiple industries with similar structure

50. How Do We Know It Works? 5th Generation in Aviation Industry
U. S. Marine Corps Adopting as Basic Philosophy
Significant Reductions in Injuries and Error
Commercial Aviation Industry
U.S. Coast Guard
U.S. Navy
U.S. Air Force
Veterans’ Administration Hospital System

51. Review What CRM is Where it came from How it works
Why we should use it
How we know it works

52. For More Information
(downloadable manual)
Okray and Lubnau, Crew Resource Management for the Fire Service. Penwell Publishing

53. Contact Information

54. QUESTIONS?